Black Pean information #31

[tronella]

Medical commentary on the final episode

The last episode is over. There are a lot of things I want to write about, but first I’ll explain about Mr Iinuma’s disease.

Proximal left subclavian artery aneurysm

I tried drawing a diagram of Mr Iinuma’s surgery.

Surgical paper on Mr Iinuma’s surgery, performed by Dr Saeki

The aorta comes out of the heart, forming the ascending aorta and the aortic arch, then sends out three branches, the right brachiocephalic artery, the left common carotid artery and the left subclavian artery, before heading to the abdomen as the descending aorta.

Mr Iinuma had an aneurysm at the root (origin) of this left subclavian artery, and in his first emergency surgery, this aneurysm was in the process of rupturing (imminent rupture).

The young Dr Saeki repaired this aneurysm and was able to suture the aortic arch to stop the bleeding, but the root of the left subclavian artery is too deep, so he was unable to treat it. He stopped the bleeding with a pean and left the pean inside the chest.

It’s true that this part can sometimes be slightly misshapen, making it very deep, so if the aneurysm is quite far along it, it becomes difficult to stop the bleeding. Also, as the name says, the subclavian artery is below the clavicle, and the clavicle can get in the way, preventing suturing to stop the bleeding. It can be treated in most cases, but we can assume Mr Iinuma had multiple different problems that made it difficult to stop his bleeding. By clamping his left subclavian artery, blood flow to the left arm is reduced, so a bypass must be placed between the left and right subclavian arteries using a prosthetic blood vessel (blood flows from the right subclavian artery through the prosthetic valve into the left subclavian artery).
When Dr Saeki left Japan for Africa, Mr Iinuma was treated by Dr Tokai Ichiro, and at this point the area around the prosthetic valve used for the bypass became infected. Dr Ichiro reopened the wound at point 3 on the diagram and investigated the infected tissue, at which point he happened to see the pean inside the chest. Then, he was seen looking at the X-ray by Dr Kurosaki. After that, Dr Tokai Ichiro was forced to leave Tojo University.

Time passed, and the pean inside Mr Iinuma’s body gradually deteriorated and loosened, causing the root of the left subclavian artery to start bleeding again. Mr Iinuma was admitted to Tojo University Hospital. Then Dr Tokai damaged the blood vessels around the pean, causing more bleeding.
I think you can tell this from the diagram, but the pean is very close to the aortic arch. Because the pean had a lot of adhesions from the surrounding area (it was stuck in), Dr Tokai damaged the aortic arch when removing the pean, causing major bleeding. I think that the bleeding before that came from the blood vessels around the pean.

Dr Saeki started the heart-lung machine, cooled the patient’s body and stopped his circulation (see previous commentaries), then sutured the aortic arch, finished the stitching, warmed the patient back up, restarted his heart and finally replaced the black pean deep at the root of the left subclavian artery again, where he was unable to stop the bleeding by other methods. Because of the adhesions, it would probably have been even more difficult to stop the bleeding by suturing that part the second time.

Also, in the scene where Dr Saeki spoke to Dr Tokai during the surgery, while waiting for the heart-lung machine to run he was just putting pressure on the bleeding part and performing cardiac massage, then once the machine was running, he continued putting pressure on the bleeding part while waiting for the body to cool. Once the patient’s body had cooled, he stopped his circulation and started suturing the damaged arch. It is actually fairly realistic that he would be able to speak during this scene. Sometimes we order the body to be cooled, then have to stand around waiting for the patient’s body temperature to drop.

Some people might be thinking that it’s unbelievable to use a pean to stop bleeding like that, but recently there was a surgery that used a “permanent clamp” to stop bleeding during a surgery, so this isn’t necessarily unrealistic. Also, most of the inside of the chest is taken up by the lungs, which are extremely soft, so I could believe that having a pean in the chest wouldn’t cause any particular problems. In fact, several decades ago in some country in south-east Asia, a pean that had been left in a patient’s body was successfully removed.

Professor Saeki’s aortic dissection surgery

Please see my commentary on episode 1 about aortic dissection.

This time, to save Dr Saeki, everyone worked together and did everything possible to save his life, which was portrayed extremely well in this scene. I felt that most strongly when Nekota started operating the heart-lung machine.

“Neko, is the heart-lung machine ready?”

“Almost.”

“Start it as soon as possible.”

“Starting it now.” Then she removes the clamp from the tube.

This is normally a doctor’s job, but if it’s to save a life, that kind of question of responsibility doesn’t matter. You can’t say it’s impossible, you just have to do it. Dr Tokai, Dr Takashina and Dr Sera were extremely realistic in this surgery scene, but Nekota’s actions were also very realistic and professional. It was a super cool scene.

Normal doctors

Dr Sera visited Dr Tokai’s home and asked his mother this:

“What kind of doctor was Dr Tokai's father?”

“What kind? A normal doctor. Always trying his best for every single patient. Sometimes he didn't come home for days.”

Dr Tokai Ichiro said this to his son:

“You’re fine as you are. Become a normal doctor. Normal people make good doctors.”

In Dr Saeki’s hospital room after the surgery, Dr Tokai said this as he was leaving:

“You're fine as you are. Normal is fine. Doctors should only think about their patients. Save them. Just save people. Those are the words of a doctor I truly respect.”

But what is a normal doctor?

The phrase “working methods reform” has spread throughout every place of work. Many young doctors who have been influenced by the new clinical training systems and only do easy work misunderstand this, think that their own working methods have to be reformed too and are rapidly, steadily stopping work.

Working efficiently, finishing your work promptly, refusing to do overtime or other people’s tasks, getting mad when things get a bit difficult or busy. Even if a patient you are in charge of takes a turn for the worse, you leave them to the doctor on duty. When your own patient has surgery, you don’t manage this yourself, just explain the task to the doctor on duty and hurry back home. You get home early and relax, go out drinking and enjoy your hobbies at the weekend. Actually, it’s because we have holidays that we can do effective work every day. Young doctors like this are increasing in number, think that doctors who stay working at the hospital are somehow inefficient with bad senses and make fun of them.

When I first started as a resident in heart surgery, my seniors never took a single holiday. At the bottom of the duty schedule it would say “Yamagishi is in training, so gets no holiday”, and even I thought that was normal. We did surgery every day, and we monitored our patients’ conditions every day. In my free time, I practiced suturing and tying knots, and sleeping at the hospital was normal. I was at the hospital so much that people told me to go home already.

If a patient I was attached to passed away, I cried. I cried in front of their family. I asked myself if there was anything I could have done, and I never wanted it to happen again. I always tried to think about what I’d done wrong, study, read a lot of papers and practice surgery.

“What kind? A normal doctor. Always trying his best for every single patient. Sometimes he didn't come home for days.”

Dr Tokai’s mother’s words really resemble the words of my own mother. My father was a heart surgeon, too. My mother said the same kind of thing as well.

In the past, all doctors were like that. At some point, the fact that many doctors spent night and day closely monitoring their patients went from being a privilege to being seen as overwork. We try to do this work that directly helps people efficiently and with good sense. Each patient only has one attending physician who is responsible for them, and they are only operated on once. Every patient wants to be operated on by the best doctors in the world, too. Do people aiming to be the best in the world work efficiently? Do gold medalists and world champions practice efficiently and with good sense?

At the beginning of my first year as a doctor, the head of the circulatory medicine department told me “The work we do shortens our lives. Take pride in that.”

Like Dr Tokai Ichiro, who threw away his own life to protect a patient, and like Dr Saeki, who risked his life to save a patient, I want to work in a way that shortens my own life.

Dr Tokai had a surgical success rate of 100%, and his genius-level surgical skill was born from his strong desire to clear the name of his deceased father. Dr Tokai looked so clear-headed at first glance, but he actually thought more about his patients than anyone else and was also thinking about his father. Because of that, he polished his skills through his abnormal, insane levels of practice at suturing and tying knots, reaching the level of a genius.

Dr Tokai himself showed how he, more than anyone, knew that it all came down to people and to people’s feelings, when he said “At times like this, your voices can reach him. Call out to him.”

With a strong feeling of wanting to save lives, I want to devote my life to my patients. “Black Pean” showed that for doctors, this is a normal stance.

This is the end of my medical commentary. Next time I will post an “afterword”.

Comments

[sarahjohnsf89.livejournal.com]

Thank you for translating

[arav10.livejournal.com]

Thank you so much for translating this. I was waiting for this episode explanation so much. I am glad that the black pean surgery part is actually possible which means this drama still trying to be as realistic as they can. Since I am not a doctor, it was nice to hear opinion about the "normal doctor" from the real doctor.

Same like him I also thought that Tokai become so genius because he put a lot of efforts. He think about his patients a lot and giving his best to save them...

I am going to miss this drama so much...

From
AR sending love to Tronella and Tokai sensei ;))